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By Gerald A. Coleman, III, DO, FACEP

Driving in to my shift in mid-December 2009, it was snowing out. As a child, I loved the snow, but as grew older, I learned to dislike its presence when I had to drive to work in it. It reminded me of my daily commute when I went to medical school in New England. I could only think of all of the stuff I had to get done before the holidays which were quickly approaching. We are all guilty at times of getting caught up in the daily grind of our lives. My mind was on the various holiday distractions but soon it would be filled with an experience that would change my life. My shift that day started out being a typical case load of chest pain, sore throats, elderly abdominal pain and dementia patients with change in mental status. Halfway through my shift, the command radio went off alerting me to a possible stroke alert coming inbound to my emergency department which was at 110% with typical inpatient holds. Their ETA was less than 5 minutes. I discharged two of my patients in preparation for this critically ill patient who was inbound. Moments later, the medic busted through the door, yelling for a doc because his “stroke alert” patient was now vomiting and becoming more confused. I rushed to bed #8, our trauma resuscitation room, to evaluate a burly 62-year-old male with a long, partially gray beard. When I asked what was going on he simply stated: “Doc, I feel like crap and my head is going to explode.” His exam was non focal but I cleared the CT scanner with the tech via phone and we rushed him over immediately because I was concerned about a non-traumatic subarachnoid hemorrhage. The patient’s GCS at this time was 14.
The next of kin showed up with another 12 family members in tow. She was visibly upset and told me that her husband John was cutting down a Christmas tree with his grandkids when he screamed out and collapsed under the tree with the ax by his side. He was found by his youngest granddaughter who ran over to her and stated, “Pop Pop is hurt, Gammy.” John came to, stating he felt like an M-80 firecracker went off in his head. The CT tech phoned over to ED asking me to come over to the CT suite immediately. He stated: “Looks like John is not going to ride his motorcycle anytime soon.”
When I arrived, I stared at the monitor and dropped my head, my worst fear was confirmed; there was a large subdural and subarachnoid space extending into the R large ventricle with substantial mass effect at the level of the foramen magnum. We rushed John back over to the ED; en route he started to violently vomit all over my scrubs. I felt this was a bad omen and prepared to RSI the patient. His airway was predicted to be difficult so I made various adjustments in positioning John prior to securing his airway. When the respiratory tech came in to the room she immediately called the operator to page anesthesia. I looked up and stated, “Please give me a chance before you call in the cavalry, what gives?” I later learned that this respiratory tech was the niece of the patient and he had had airway trouble in the past with elective surgery. After I intubated John on the second attempt and made appropriate arrangements to transfer him to the receiving hospital, I sat down and talked to his family.
I walked into that room with a very uneasy feeling about the outcome of this case. One of the things that I learned early on in my career when dealing with families during a difficult case is to be truthful, direct, and professional. His wife asked me a direct question to which the entire room hung on my every word: “Dr. Coleman, is my husband going to die; you know his dad died the same way.” I had been through the gut-wrenching experience of losing a child at birth during my residency, so her fear was palpable and personal to me. This experience brought back unpleasant images of my deceased daughter. I simply stated while trying to ignore a salty tear streaming down my face, “We are going to do everything in our power to help John, I am in full court mode right now, take one step at time, he is a fighter, we can only hope for the best and prepare for the worse, time will only tell.”
Medevac had aborted the round trip 35-minute flight to the receiving hospital due to snow and low visibility, so my ground ALS crew was standing by to take John. I had to send an RN with John and the ALS crew because I started the following intravenous drips: cardene, mannitol and proprofol. John made it down to the receiving hospital’s interventional radiology suite in record time: door to IR suite within 86 minutes. This was amazing considering it was a 52-mile ground transport in suboptimal driving conditions.
After the dust settled, John had a protracted course in the ICU, staying there and in rehab for the next 4 months. He was finally discharged. Life went on in the ED as usual and a year passed. That year was a rough one for me because I survived my first year as a medical director after only being board certified for 6 months. A year later, to the exact day that John had his near fatal subarachnoid hemorrhage, I was working clinically when a middle-aged male without a beard come up to the physician charting area of the ED. I politely asked, “How can I help you today?” This gentleman’s eyes had strange familiarity to them. I said to myself, “Where have I seen this guy before?” He replied: “Hi Dr. Coleman, my name is John, and I wanted to say thank you in person for saving my life and giving me a second birthday.” I stood up for the desk in utter shock, “My god, John, you look amazing.” He had lost a ton of weight and lost the beard. He walked me to the conference room and there were more than twenty of his family members waiting to see me. Anyone who knows me well knows that I have an iron-clad exterior but at times can be emotionally sensitive when the time is right. I became overwhelmed with emotion as I listened to his family tell me John’s success over the last year in his recovery. We exchanged hugs, tears of joy, laughs, and simple stories of the heart. There are defining moments in your career; this was one of mine.
I firmly believe that everyone has a role and a purpose on this earth; mine was right here being an emergency physician. After a brief celebration with John’s family, he came over to me and said, “Dr. Coleman”; I immediately corrected him and said, “Please call me Jerry. “ He said, “Sure, Jerry, come outside, I have a surprise for you.” John was a lifelong motorcyclist and had an obsession for Harley motorcycles. During his ICU stay, I learned from numerous conversations with his wife that John’s goal was get back on his bike and ride again. When I stepped outside of the ED ambulance entrance, I saw a huge Harley Davidson bike sitting there. John asked ”Hey Jerry, you gave my life back, can I take you for a spin.” I stated, “I would love that, but John, my patients are waiting, I hope you understand. Can I take a raincheck on this one?” He understood. We embraced with a handshake that turned into a “man hug.” He again said thank you. I simply stated, “John, I did what I was trained to do, trying to save lives and alleviate suffering.” I walked back through the doors of the ambulance entrance, and picked the next chart with a renewed sense that I am doing what I was meant to do.
What I learned from this case is that life is far too short. Sometimes through personal life experiences or extraordinary cases such as this one, we are reminded that we need to take a step back and realize what is truly important in this world. Take time to enjoy life’s simple pleasures; tell people you love them unconditionally because you never know when your time is up.

A bill that requires drug manufacturers to report to the FDA when a shortage is on the horizon – or when a drug would be discontinued – recently received two additions that would help physicians as they battle shortages in emergency departments. ACEP, working with several other emergency care organizations, was instrumental in getting language included in the bill that states “a sterile injectable product” or “used in emergency care or during surgery” would also qualify. The legislation currently sits in the Senate Committee on Health, Education, Labor and Pensions legislation. The Senate HELP committee is scheduled to meet April 25. Similar legislation will begin working its way through the House Energy and Commerce Committee next week. The FDA reports that shortages have increased since 2010, when it listed 178 drugs that were in short supply.

Please send YOUR story to Tracy Napper at tnapper@acep.org.

Tonight a 17 year-old boy came to the emergency room complaining of headache. As I entered his room, in my usual hurry to do an assessment as expeditiously as possible, so as to get on to the next case and attempt to avoid the inevitable backup of patients so common in our ER, I was struck by the vulnerable demeanor of the patient before me. The triage nurse’s report assured me that the temperature and other vital signs were normal (unlikely to be the dreaded meningitis, I thought) and that no trauma has prompted this visit.

At the youth’s bedside sat his mother, a woman of about forty years. She waited quietly with a soft, though concerned and vigilant look on her pretty face. Early on in the encounter she informed me that her son had been having occasional headaches for two years but that the symptoms had worsened in frequency and intensity over the past couple of months. Not only were the headaches worse, but the boy also wanted to sleep a lot and was “difficult to wake up.” My thoughts immediately turned to a possible diagnosis of some sort of brain lesion, namely a tumor, though rare in this age group, nevertheless consistent with the presenting symptoms. While conducting the physical exam, with special attention to the neurological system, I asked the mother if her son had ever had a CT scan during the time he has been suffering from these headaches. She remarked that indeed he had undergone such a test two weeks earlier, when one of my colleagues had evaluated him in our ER and that the scan had been normal.

This news gave me some measure of comfort, though MRI is a more sensitive method for ruling out a brain tumor. I now headed down the migraine pathway as the route most likely to lead me to the correct diagnosis. Certainly there was a migraine history in the family and this young man was a likely candidate for such an affliction. Dear God, let it be migraine, I silently prayed, so I can treat it and get on to the next patient. I could see that the ER was getting busier and I, the sole physician on duty, would pay the price of keeping other patients waiting.

I quickly reviewed in my mind the facts of the case, but the most remarkable feature was the mother’s insatiable need for reassurance that her son had no life-threatening condition.

Initially, the young man would not respond to my inquiries as to the nature of his headache, such as when it started, where exactly it was located, whether he felt nauseated or had any visual disturbance, ie, the usual questions asked of every patient presenting to the ER with pain in the head. I began to appreciate his mother’s concern that he just wanted to sleep and was difficult to wake up. Finally, suspecting that he really could hear and understand me, I took the assertive maternal approach and told the boy to sit up and cooperate with the exam. Much to my relief he responded in an appropriate manner, a clear sign that his level of consciousness was not impaired, an important thing for me to know.

Yet, he looked so sullen.

By the third time his mother asked if I was sure he was all right and I was beginning to wonder what on earth was causing her so much worry, when I had, I thought, in my usual caring and compassionate manner, done everything I could think of to allay her fears, she remarked, ”I’ve already lost one son, I couldn’t bear to lose another.”

Suddenly any hope of getting out of that room quickly and on to the next patient was seriously compromised. I was now compelled to ask the inevitable question of what had happened to her other son. Thoughts of a dreaded, rare, familial disease that presented with headaches and took the lives of children, and which I could not remember from my medical school days, raced through my mind. I glanced at this pathetic-looking woman, whose desperation I could feel in my own heart, and, as gently as I could, asked the awful question.

“He was murdered two months ago,” she said, with what must have been more courage than I could only imagine a mother could muster up. Her words stung me. Suddenly the whole case took on a different light and as I looked again at my young patient I now saw the obvious face of grief and depression.

Often in a busy ER doctors and nurses alike, because of a myriad of stresses inherent in the work, become impatient with and, at times, intolerant of some of the members of society who “bother” us with seemingly minor complaints, especially if they are repeat visitors to our hospital. Everyone knows that teenagers tend to be moody, uncooperative individuals who often don’t want to get out of bed. But how many of us have ever had to endure what this young lad had experienced? His older brother, his idol, has been killed, shot by two men who hijacked his car and left the young man and his companion dead in a Florida orange grove. Why would anyone want to get out of bed again after that?

Emergency medicine is a challenge, to say the least. Each 12-hour shift teaches something. Patients come and go. Life hangs in the balance.Sometimes the pace is frenetic and survival (my own) is questionable. Many people come to our doors and we may never know what pains lie hidden in their hearts. Usually the diagnosis is easy, the physical problem obvious and treatable. Though life-threatening events happen every day in the ER, in most cases we can make a positive difference, occasionally even saving a life.

The problems of the heart (not in a cardiac sense) are often the most difficult to treat.

I am reminded each day that life is precious, that today might be my last on this earth, that I am honored and privileged to be an ER doctor and to be entrusted with the health and lives of the many patients who seek sanctuary inside our doors.

But every once in a while I stop to reflect and savor the moment and one such time was tonight when, after having a heart-to-heart talk with a wounded mother and her son, a 17-year old boy gave me a hug as he left my ER.

Marlene Buckler, MD, FACEP